Category: News

Suffering in Silence: The Biases and Data Gaps of Menopause

Female Founders Fund launched in 2014 with one simple belief: women will build the companies of tomorrow. Since 2014 women’s health has outgrown its perception as a “niche” area of healthcare and developed into a key area of interest for investors, as well as the broader healthcare community. As a result of this shift, over $1 billion has been invested in women’s health companies over the last 5 years.

We invested early in Maven Clinic in 2014 and through our experience with Maven have become increasingly aware of both the need to create specific solutions for women’s health, and the opportunity to consumerize healthcare and put it in the hands of the user. We believe that women’s healthcare is a global market opportunity in a nascent stage, primed for exponential growth. Globally, billions of dollars are spent on women’s healthcare each year, yet in many areas, outdated approaches and barbaric standards of care still persist.

We see immense opportunity for improvement in women’s health through both technological and business model innovation. Women are the primary decision-makers in healthcare choices for both herself and her family, controlling over $2T of spend annually. After Maven, FFF invested early on in other category-defining women’s health companies including Shine (a consumer self-care platform), Real (a mental health platform for millennial women), and most recently Oula (a service reimagining how women experience pregnancy and delivery).

“Women are not just small men, and there is much work to be done to better understand and serve 50% of the population”

The Data Gap

Women at every age are impacted by the lack of historic research and focus on women’s health. In her book “Invisible Women”, author Caroline Criado Perez writes that the medical system is “from root to tip, systematically discriminating against women, leaving them chronically misunderstood, mistreated and misdiagnosed”. While women have been seen as “complicated” and largely excluded from drug trials due to menstrual cycle fluctuations, men have been the default. The FDA recommended excluding women from clinical trials in 1977 and did not reverse that stance until 1993. While the number of women who participated in clinical trials that led to FDA drug approvals had increased to 72% in 2019, just a year earlier in 2018 only 56% of trials included women. Women are not just small men, and there is much work to be done to better understand and serve 50% of the population.

The World is Aging

By 2030, the median age in the U.S. will be 40, up from today’s 37, and there will be more women between the ages of 40 and 64 than women under 18, according to the 2017 U.S. Census projections. There are ~170M of women in the US and 3.8B women globally, all of whom have gone through, or will go through menopause. An estimated 1.1 billion women throughout the world will be postmenopausal by 2025. There is a wide range for age of onset, with some women losing their menstrual cycle in their 40s and others in their late 50s. This age range means that menopause often hits women at the height of their careers, making menopause not only a concern for the physical and emotional wellbeing of women, but also the economic wellbeing of employers and nations.

“1.1B women throughout the world will be postmenopausal by 2025”

Investment Opportunity

Today, women make 85% of all consumer purchases and control 80% of all healthcare decisions in a $3.5T healthcare industry. Every woman will experience menopause which lasts on average 4–10 years, and costs an average of $20k in trial-and-error spending on prescriptions, doctor visits, treatments, devices and products. Many women don’t understand menopause, when it happens, and even if they are in menopause at all. According to PitchBook data, femtech startups have raised more than $498 million in 2019 alone; however, only 5% of femtech startups address menopause, a market which is estimated to reach $5.3B by 2023. Globally, menopause startups have raised $254 million to date since the start of 2009. For comparison Hims, just one company that targets erectile dysfunction among other male concerns, has raised nearly $160M and was most recently valued at $1.6B.

What We Are Doing About It

While there has been medical advancement in birth control and fertility options, menopause is an area that has seen little innovation, despite the considerable and often long-lasting impacts on women’s everyday lives. Over the past twelve months we have seen an increasing number of startups in the menopause space, yet in our due diligence we found a surprising lack of existing research on what consumers want and need. As understanding is a precondition to improvement, Female Founders Fund conducted a survey of 250 women to gain a better understanding of the overall needs of women throughout their menopausal journey. We are going to explore the most interesting findings from that survey below.

What is Menopause?

Menopause is the confluence of two subjects, women’s health and aging, that have long been shrouded by cultural taboo. Menopause marks the end of a woman’s menstrual cycle and is diagnosed after a woman has gone 12 months without a menstrual period. The average age of onset is 51 in the US, with most women entering menopause in their 40s or 50s. Symptoms are both physical, such as hot flashes, weight gain and loss of libido and psychological, such as mood swings, difficulty concentrations, depression and anxiety. The top ten symptoms that respondents indicated experiencing are as follows: hot flashes (80%), night sweats (77%), sleep disorders (71%), loss of libido (70%), mood swings (69%), fatigue (67%), weight gain (67%), irregular periods (64%), bloating (63%) and difficulty concentrating (63%).

“78% of respondents indicated that menopause interferes with their lives”

78% of respondents indicated that menopause interferes with their lives, and 23% of respondents indicated that menopause impacted their lives either “a great deal” or was “completely debilitating”.

There are a total of 34 symptoms a woman can experience in menopause, some women experience no symptoms, while others experience mild/severe, and multiple symptoms. As one respondent put it “I have continued to experience multiple menopause symptoms and wonder if it will ever end”. The chart below shows the prevalence of symptoms in survey participants.

The Big Question: Hormones vs. Holistic

Women entering menopause currently have two options to mitigate and manage their symptoms: hormonal therapy and diet/lifestyle modification. Hormone therapy is medication to replace the estrogen and progesterone levels that are reduced during menopause.

There are two broad types of hormone therapy — systemic hormone therapy and low-dose products. Systemic hormone therapy comes in the form of pill, skin patch, ring, gel, cream or spray form and typically contains higher doses of hormones that are absorbed throughout the body. Low-dose products come in cream, tablet and ring form and tend to be vaginal only preparations designed to treat vaginal and urinary symptoms of menopause only. There are both synthetic and bioidentical hormone preparations available. In the largest clinical trial to date, hormone replacement therapy that consisted of an estrogen-progestin pill (Prempro) increased the risk of certain serious conditions including heart disease, stroke, blood clots and breast cancer. Nearly twice as many survey respondents indicated that they did or would not use hormone therapy for managing menopause (56% indicated they did or would not versus 28% indicated they did or would). Concern about breast cancer (25%) was the top reason why respondents did or would not use hormone therapy.

“I fear the negative side effects and have been advised against hormone therapy”

Holistic approaches to managing menopause symptoms focus on overall wellness practices and supplements to help ease the body’s transition. According to survey respondents, the most successful holistic treatments include exercise (107 respondents), dietary changes (79 respondents) and supplementation (69 respondents). There were a range of supplements taken by survey participants and they included black cohosh, maca, Promensil and 5HTP among others.

“Only 36% of respondents felt moderately or very prepared for menopause”

Opportunity: What Do Women Want?

Women want to feel better prepared for menopause and want more clarity on what treatments will actually help alleviate their symptoms. Only 36% of respondents felt moderately or very prepared for menopause, which is unsurprising given nearly the same number of respondents get information and support around menopause from friends (131) as they do doctors (149). 32% of participants indicated that their healthcare providers are not knowledgeable/confident discussing menopause, a strong indicator that healthcare providers need to better educate and support their patients. As one respondent explained “it was a mystery and a challenge to know and manage such a wide range of symptoms. My husband certainly didn’t know or expect me to have such mood swings or hot flashes or reduced libido or headaches and intense need for my own space and my own bed.”

Given the lack of adequate healthcare support, there is opportunity for companies to step in to provide additional support. However, advertising is often difficult for femtech companies as platforms such as Facebook block ads for menopausal products, deeming them too “adult”. While male-focused brands like Roman and Hims are able to run ads on Facebook for products that enhance male libdio and mention erectile dysfunction and condoms, there is a double standard. The menstrual cycle is so far from being adult or pornographic, yet it is being censored as such. Indeed, only 41% of survey respondents have seen advertisements for menopause products. Television ads (36%) and Online/Social Media ads were the most frequently seen (36%). There is also opportunity for communities to form around menopause, with 71% of respondents indicating they would benefit from such a community. From a product standpoint, when asked what menopause product has been or will be the most beneficial, the top response was that women do not know (75), followed by hormones (37) and supplements (30). Interestingly, even for non-hormonal alternatives, 53% of women would like products to be prescribed by their doctor. 36% of respondents would prefer to purchase non-hormonal alternatives directly from a company followed by 31% who would prefer to purchase products over the counter in a store.

“Reproductive healthcare still makes up 95% of the femtech investment space, with investment in menopause only accounting for 5% of femtech investment”

Startup Landscape

There is demand for innovation and we have seen a variety of different startups emerge to address the market need. It is important to keep in mind that reproductive healthcare still makes up 95% of the femtech investment space, with investment in menopause only accounting for 5% of femtech investment. Startups from telehealth to supplements have begun to pop up to address the market need.

Telehealth /Medical Platforms: Genneve, founded in 2015, is one of the older telehealth menopause care providers which raised a $4M seed round led by BlueRun Ventures. Competitors include The Cusp, founded in 2018, that has also raised a $4M seed round. Elektra Health and Peppy Health are newer players in the space. Lisa Health provides data-driven, science-backed insights and therapeutics for women going through menopause.

Products: Thermaband and Embr provide temperature regulation for women experiencing hot flashes. Attention Grace provides bladder leakage solutions. Joylux provides vaginal rejuvenation products. Pause provides skincare products for aging skin.

Supplements: Kindara provides non-hormonal nutritional supplements as well as lubricants. Mighty is another example of a dietary supplement provider.

Community/Content Solutions: Caria, founded in 2019 offers a community of support as well as symptom tracking.

What’s Next

While we are encouraged by the startups beginning to emerge, menopause is a $600B+ opportunity that is still largely untapped. Women during this phase are looking for solutions that fall into the four key areas listed above that represent an enormous market opportunity. Women want and deserve better informed and communicative doctors, more information around what products and lifestyle interventions work, and a community to support them along this important life transition.

“ I felt alone and not believed about the severity of my symptoms”

The menopause tech revolution is long overdue, yet finally beginning. Women deserve better, and we are optimistic about the opportunity for innovation to drive impact.